ERROR RISKS AMONG POPULATIONS OF SPECIAL VULNERABILITY

The safety of all patients is of paramount concern for all healthcare providers. However, some patients—for example, the very young, the very old, and the very sick—are particularly vulnerable to the effects of medical errors, often due to their inability to participate actively as a member of the healthcare team due to communication issues. In addition, their physical status (including but not limited to body weight and body mass composition, nutritional status, and metabolism) may also cause them to react differently to interventions, putting them at special risk. Healthcare providers must recognize the special needs of these patients and act accordingly.

Older Adults

There are multiple issues of concern when providing healthcare to adults ages 65 and over. Failure to recognize the unique problems of this age group can result in adverse events.

POLYPHARMACY

Older adults often are taking multiple medications (polypharmacy), creating a significant risk for adverse drug events. Medication management in the older adult population involves considerations for drug dosing, drug interactions, adverse effects, adherence, social issues, clinical practice guidelines, and altered physiology (Nguyen et al., 2020).

COGNITIVE IMPAIRMENT

Confusion and/or delirium in the older adult, especially someone with preexisting cognitive impairment, can be due to certain aspects of hospitalization, such as changes in environment and sensory deprivation. Delirium can also be the result of polypharmacy. Effective measures include orientation protocols, environmental modification, nonpharmacologic sleep aids, early and frequent mobilization, minimizing use of physical restraints, use of vision and hearing aids, adequate pain relief, and reduction in polypharmacy (Mattison, 2020).

FUNCTIONAL DECLINE

When an older adult is hospitalized, functional decline can occur as early as the second day of hospitalization. Immobility can increase the risk for adverse events such as falls, delirium, skin breakdown, and venous thromboembolic disease. Improved mobility during hospitalization has been linked to decreased risk of death. Activity order for bed rest should be avoided unless absolutely medically required. Patients should be assisted out of bed to a chair for meals, which can also decrease the risk of aspiration, and should be encouraged to walk several times a day (Mattison, 2020).

FALL RISK

Risk for falls is increased in the older adult and may be due to the effects of acute illness compounded by an unfamiliar environment and side effects of treatments. Tethering medical devices such as urinary catheters, IV lines, cardiac monitor leads, and restraints make it more difficult to mobilize patients safely and are associated with increased rates of delirium, infection, and falls.

Strategies to help prevent falls may include weighing the risks and benefits of medications with significant psychotropic and anticholinergic effects, monitoring patients when prescribed drugs that may increase fall risk, supervising high-risk patients when ambulating, and encouraging time out of bed walking or sitting in a chair to prevent orthostatic hypotension associated with prolonged immobility (Mattison, 2020).

(See also “Falls” earlier in this course.)

MALNUTRITION / DEHYDRATION

Malnutrition and dehydration in hospitalized and nursing home older patients may result due to impairment in cognition, restriction of movement, no access to dentures, difficulty with self-feeding, missed or interrupted meals, reduced appetite due to illness or lack of activity, lack of assistance with meals and drinks, and severely restricted diet orders, such as nothing by mouth.

Simple interventions such as getting the person out of bed at mealtime and providing assistance with eating can be of benefit. Inpatient assessment by a nutritionist can identify deficiencies and, combined with nutritional follow-up after discharge, may decrease mortality (Mattison, 2020).

Infants and Children

The potential for adverse drug events is higher in the hospitalized pediatric population than in hospitalized adult patients due to pharmacokinetic parameters and the need for precise dosage measurement. For this reason, accurate weight scales, standardized equipment throughout a system, drug dose range limits, programmable “smart” infusion pumps for hospitals, and standardized order sets should be used.

Pharmacists can be consulted to check dosing calculation, screen for drug-drug interactions, and educate caregivers regarding proper administration and medication storage safety.

Infants and young children do not have the communication abilities needed to alert clinicians to effects they experience. Parents of infants and children need to be fully informed and involved in their child’s care during any encounter with the healthcare system and must be educated to question caregivers about medications and procedures (Wu, 2018; Mueller et al., 2019).

Intensive Care Patients

Intensive care settings are one of the most complex environments in healthcare. Medical errors and deaths due to preventable harms are more common in the ICU due to higher patient acuity and complexity of care. A safety smart list integrated into intensive care patients’ electronic health records has been found to decrease complications and length of stay in the ICU. The checklist covers common ICU conditions that, when left unaddressed, have been associated with HAIs, thrombosis, and worse clinical outcomes (Lemkin et al., 2020).

Patients with Limited English Proficiency (LEP)

Individuals with LEP have problems with language competence that negatively affect communication and can greatly define the ease with which they navigate all areas of the healthcare system. They are at higher risk for complications because of poor comprehension of medication errors, inaccurate assessment, increased psychological stress, and poor compliance with treatment and follow-up. In addition, the use of family or friends as interpreters increases chances of error (Claros, 2021).

Both the Joint Commission and the Affordable Care Act mandate adequate medical interpreter and translation services for patients who have LEP. Translation and interpreter services provided by Certified Medical Interpreters is the gold standard (Goodwin, 2018).

Patients with Low Health Literacy

Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low health literacy may have a negative effect on a person’s adherence to a treatment regimen and may impact parent/caregiver behavior and children’s health outcomes (ODPHP, 2020).

Since limited health literacy is common and may be difficult to recognize, it is recommended that clinicians assume all patients and caregivers may have difficulty comprehending health information and that they communicate in ways that anyone can understand. Improving health literacy includes:

Simplifying oral and written communications
Confirming comprehension for all patients and caregivers
Making the healthcare system easier to navigate
Supporting patients’ efforts to improve their health
(ODPHP, 2020)